Hospice eligibility guidelines: Parkinson's disease

Parkinson's disease indicators

The guidance describes three pathways. Any one supports the prognosis. It looks at change over the 12 months before certification. Parkinson's usually arrives by the second or third pathway, after years of slow decline.

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

Points specific to Parkinson's disease

The late stage is Hoehn and Yahr stage 5: wheelchair-bound or bedridden unless aided. Document the stage, the hours of "off" time, the response to levodopa and whether dose adjustments are limited by hallucinations, orthostatic hypotension or dyskinesia. Loss of levodopa response is a prognostic turning point worth stating plainly.

Dysphagia drives most of the complications: aspiration, weight loss and the feeding tube decision. Record swallow evaluations, diet texture changes and aspiration events with dates. Dementia is common late in Parkinson's and defines Lewy body dementia; when it is present, the dementia guidance (FAST stage 7 plus a complication) may fit better than the neurologic pathway, and either may be used with the general decline indicators.

The related disorders progress faster than idiopathic Parkinson's: progressive supranuclear palsy and multiple system atrophy often reach pathway 2 or 3 within a few years of diagnosis, and MSA adds autonomic failure and stridor. Note the specific diagnosis; it changes the expected trajectory.

Supporting documentation

• Diagnosis and date, Hoehn and Yahr stage, and the specific disorder if not idiopathic Parkinson's.
• Functional change over 12 months: walking, transfers, speech, swallowing, diet texture, self-care, with dates.
• PPS or KPS over time; dependence in activities of daily living.
• Levodopa response: dose history, hours of off time, limiting side effects.
• Weight trend; swallow evaluation results; the feeding tube decision.
• Aspiration events, infections, pressure injuries, falls with injury, hospital and emergency visits.
• Cognitive status and hallucinations; the dementia stage where present.
• POLST and advance directive status; who makes decisions when the patient cannot.

Comorbidities

The Medicare hospice LCD guidance weighs comorbidities as well as the primary diagnosis. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

Heart disease, COPD and dementia commonly co-occur and shorten the prognosis; document their stage and treatment. The eligibility scales page has the PPS and FAST tables referenced here.

What if you are not sure a patient is eligible for hospice?

If you are not sure a patient is eligible for hospice, call Beta Hospice and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything. Parkinson's families often ask about hospice late, after a fall or a pneumonia. An earlier conversation about goals is usually welcomed. Prognosis is rarely clear cut.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Beta Hospice's family guide, hospice care for Parkinson's disease, explains in plain language what hospice does for this illness, what signs are worth raising with a doctor or nurse, and how care is paid for. It does not give an eligibility verdict. Families often ask the same questions you are weighing, in different words. You are welcome to share it before or after a goals-of-care conversation.